Nokea
The nurse is caring for a client who states, 'I am really worried about the thoracentesis. I know I won't be able to sleep tonight.' Which statement is most helpful to the client at this time?
- A. Tell me what you are worried about.'
- B. Is there something that I can help you with?'
- C. Is there someone that you would like me to call to be with you?'
- D. The physician will see you before the procedure and can answer any questions.'
Correct Answer: A
Rationale: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client expresses being worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the client makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.
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The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
- A. A puncture at the radial artery
- B. The trachea and bronchi
- C. The pleural surfaces
- D. A catheter in the arm vein
Correct Answer: A
Rationale: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
- A. Blood gases
- B. Complete blood count
- C. Blood chemistry
- D. Serum alkaline phosphate
Correct Answer: A
Rationale: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.
What would the instructor tell the students purulent fluid indicates?
- A. Cancer
- B. Infection
- C. Inflammation
- D. Heart failure
Correct Answer: B
Rationale: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
- A. Crackles
- B. Sonorous wheezes
- C. Rubs
- D. Sibilant wheezes
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
- A. My study is scheduled for 10 AM, several hours after I eat.'
- B. I brought comfortable clothes and shoes for the test.'
- C. I am ordered a bronchodilator to note lung improvement following use.'
- D. I will breathe in through my mouth and out through my nose.'
Correct Answer: D
Rationale: The nurse would clarify the client's statement of improper breathing technique. During a pulmonary function test using a spirometer, a nose clip prevents air from escaping through the client's nose when blowing into the spirometer. All other statements are correct.